Rose, A. (2020). Shame-to-cynicism conversion in The Citadel and The House of God. Medical Humanities, 2020, 1-10. https://doi.org/10.1136/medhum-2020-011882

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Shame-to-Cynicism Conversion in The Citadel and The House of God

This article considers a dynamic conversion process in the relationship between cynicism and shame, as experienced by doctors. Shame develops when medical professionals fail to live up to ideals of practice. Disavowing this shame converts it into a cynicism about the ideals themselves.

Although this cynicism proves to be a strategic virtue when accepted as part of a clinician’s emotional toolkit, it is all too frequently pathologized for complicating or problematizing these ideals.1 Pathologizing nascent cynicism produces further shame that extends beyond the original failure of practice to encompass a chagrin about a loss of ideals. This conversion process explains a correlation between the frequently noted cynicism at work in A. J. Cronin’s The Citadel (1937) and Samuel Shem’s The House of God (1978) and the largely ignored moments of shame that mark both novels. In the discussion that follows, I establish the presence of a sociological shame-to- cynicism conversion model that translates across the historical, geographical and structural divide separating the two novels. My choice of these two novels as the illustrations of this model is far from arbitrary: their overwhelming historical influence, on the development of healthcare systems, as contributions to the “hidden curriculum” of healthcare training, and in shaping the conception of the doctor for all participants within healthcare contexts, means that their staging of the shame- to-cynicism conversion may well have wider implications than the mere reading of fiction. While medical education has long been concerned with the effects of cynicism, often in relation to burnout, there is little that considers the effect of its relation to shame, or on the influence both have in the formation of health professionals.2

I offer this work as a prolegomenon to a more detailed genealogy of the shame-cynicism dynamic in fictions and memoirs written by clinicians, in preparation for further interdisciplinary study of its effects in medical education. I begin by establishing the significance of these novels as bildungsroman that have influenced the wider imaginary of practitioner development. Then, I considers how the novels reflect the institutionalization of medical bildung, as theorized by Erving

Goffman, paying particular attention to Goffman’s interest in cynicism and shame. Such processes can be linked, I argue, through a shame-to-cynicism conversion, a process modelled on Bonnie

Mann’s concept of the shame-to-power conversion, which occurs in the formation of sovereign masculinity. Returning shame-to-cynicism conversion to Goffman’s institutionalization can, I conclude, identify a hitherto unacknowledged relation between institutionality and affect that explains the novels’ lasting appeal to the hidden curriculum in medical training, formation or bildung.

The Influence of The Citadel and The House of God

A. J. Cronin’s fifth novel, The Citadel, follows its protagonist, Andrew Mason, from his first position as a medical assistant in a Welsh mining village through his work for a Medical Aid, his move to London to advise the Coal and Metalliferous Mines Fatigue Board, then his turn to private practice, and finally his decision to open a cooperative clinic based on the principles of evidence based medicine. One does not need to endorse the popular fiction that it inspired the UK’s National

Health Service to admire the novel’s profound influence over the medical profession in the more than eighty years since it was published.3 The medical memoirist, Adam Kay, in his introduction to the 2019 revised edition, calls it “a statement of intent that is still relevant over eighty years

later. It’s a warning from history that genuinely changed the future”.4 Certainly, it sold and sold well: 150,000 copies in its first three months, 10,000 each month after that until the end of 1937.5

Its numerous reprints sported the dust jacket quote “One of the 3 or 4 most famous novels of the last twenty years”.6 It was immediately popularized by a film version by King Vidor (1938); further film adaptations followed in Hindi (1971), Bengali (1972) and Telugu (1982), as well as television adaptations in the US (1960), Britain (1960 and 1983) and Italy (1964 and 2003). This success was not without controversy: Sally Dux demonstrates that the proposed Vidor adaptation faced scrutiny from censors in 1937 because of concerns that it might “shake” or “damage” the public’s faith in the medical profession.7 Seamus O’Mahony suggests three reasons for its contemporary success:

“a) timing, b) the novel’s accurate portrayal of a dysfunctional medical care system easily recognisable to its readers, and c) Gollancz’s genius for promotion.”8 The novel was canonized for being a timely attack on a dysfunctional medical system, even as it enjoyed financial success and a longevity of influence on the mores of health professionals. In this, it resembles a stylistically quite different novel published some 40 years later: Samuel Shem’s The House of God.

Shem’s first novel, The House of God, chronicles Roy Basch’s year-long internship at the House of God (modelled on Shem’s internship at the Beth Israel Hospital in Boston) and his relations with his fellow interns, his mentor (the Fat Man), the Chief Resident and Chief of Medicine and his girlfriend, Berry. Like The Citadel, it has enjoyed significant financial success alongside its longevity as a critical medical bildungsroman: over three million copies have been sold, in some fifty languages. Successive anniversaries, in 1995, 2008 and 2018, have produced a wealth of critical reflections.9 Again, this impact is, perhaps, a matter of timing and of portrayal. The physician and historian of medicine, Kenneth M. Ludmerer, notes that the novel “struck a chord”

in the years after its publication that challenged the status quo: “younger doctors loved the book, while older physicians pilloried him for having written it.”10 Like The Citadel, it presented an attack on the system, making “a mockery of the serious, dignified process of transforming a callow medical student into a mature physician.”11 According to Ludmerer, Shem’s account of residency training “accurately portrayed the conditions of residency it satirized, and that the underlying conditions that led to fatigue, burnout and cynicism […] have not substantially changed in the three decades since the appearance of the novel.”12 This by no means comprehensive review of the reception histories for The Citadel and The House of God should impress upon the reader the sway that these novels have had, and continue to have, in shaping a popular imaginary about inherent problems in the medical formation or bildung of doctors, and in contributing to a hidden curriculum, understood to be the unofficial or informal means by which professionals are trained, educated, or socialized. This influence is in no small way related to the way that the novels are positioned as auto-commentary or thinly veiled fictions by trained clinicians (i.e. as individual,

“cynical” responses to processes of medical training and practice “authenticated” by insider authors).

Both novels have certainly been read as medical Bildungsroman. For Anne Hudson Jones, identifying The House of God as such, the bildungsroman “focuses on the education and maturation of a young man who is set apart by some special gift, such as heightened sensitivity, artistic talent, or remarkable intellectual capacity, while the medical bildungsroman is a specialized version of this subgenre in which a young physician, often but not always an intern or resident, sets out to find his special calling and to master his craft”.13 O’Mahony appeals to this notion of bildung, when describing The Citadel as “the struggle of the idealistic young hero against the

medical establishment, which is corrupt, venal, unscientific and self-serving”.14 So too The House of God, albeit with one notable exception: whereas The Citadel took aim at an medical establishment that was “unscientific”, The House of God targeted a medical establishment whose scientism had begun to obstruct patient care. Denis Noble observes that the corruption and venality of The House of God manifests as overt scientism: “medicine then becomes working out what molecular problems are and fixing them”.15 Shem’s emphasis on the need to bring care back into evidence-based medicine presents the mirror image of Cronin’s earlier desire to introduce evidence into medicine to liberate it from quackery. Written on either side of what O’Mahony has elsewhere described as the “Golden Age of Medicine” (roughly 1930 to the mid-1980s), both novels use the bildungsroman as the formal means to launch a social critique of medical establishments characterized by different, even contradictory problems.16

To align the texts more precisely, across their historical divide, we might turn to one concern that they share: the relationship between medical care and profit. This interest in profit provides an entry point into the forms of cynicism at work in the novels. An emphasis on profit often produces cynicism: after all, the cynic, Oscar Wilde famously quipped, “knows the price of everything and the value of nothing”.17 So, we might observe that a concern for economic or social capital drives many of the characters into patterns of behavior that detract from the care of the patients. For

Cronin, writing in Britain prior to the establishment of the National Health Service, the medical system is rigged to profit doctors that attend to their bills more than their patients. For Shem, the system of retaining patients who might be better served by being discharged (i.e. “gomers”) is designed to maximize profits for the hospital and for the private attendings. In forcing idealists to challenge their complicity with such systems, however, such cynicism carries, even causes, shame.

Paradoxically, cynicism also provides the means to disavow this shame, as it forms a necessary, if imperfect, shield of detachment for the otherwise implicated clinician.

Shame appears to sidestep a discussion of detachment and cynicism. If anything, both detachment and cynicism suggest a repudiation of, or indifference to, shame. Shame does not seem a significant point of difference between the two. After all, the key distinction between detachment and cynicism is motivation. Whereas detachment maintains a belief in the wider ethos of an activity, cynicism undercuts that belief by considering the undue influence material benefits exert on this ethos. When William Osler, the so-called father of modern medicine, advocated the cultivation of equanimity, the antecedent to medical detachment, in the medical encounter, he warned against the emotional cost of “large and successful practice”: “Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.”18 For Osler, the pursuit of profit displaces “those gentler influences”, but it also hints at the risk cynical motivations pose to the ideals of equanimity or medical detachment, “laying waste” to one’s powers and “giving away” hearts. Osler, however, introduces shame as further impediment to equanimity. Earlier in his lecture on “Aequanimitas”,

Osler suggests shame presents a more immediate risk to a clinician’s “imperturbability”:

Far be it from me to urge you, ere Time has carved with his hours those fair brows, to

quench on all occasions the blushes of ingenuous shame, but in dealing with your patients

emergencies demanding these should certainly not arise, and at other times an inscrutable

face may prove a fortune. In a true and perfect form, imperturbability is indissolubly

associated with wide experience and an intimate knowledge of the varied aspects of

disease.19

The suggestion, then, is that if cynicism imperils the clinician’s equanimity by causing them to feel too little, shame is equally dangerous for causing them to feel too much. We can find echoes of Osler’s message in The House of God, when The Fat Man, Roy’s cynical mentor and the novel’s leading exponent of care-based medicine, reproves Roy for speaking too frankly with his patients’ families: “Some things have to be kept private, Basch. You think parents want to hear schoolteachers making fun of their kids?” (268) If equanimity demands the clinician “quench the blushes of ingenuous shame”, however, its pathological excess, cynicism, risks extending this quenching process to “all occasions”.

To explore this quenching further, I want to take The Citadel and The House of God as exemplary accounts of the dynamic that exists between clinician cynicism and clinician shame, even if they are not, in themselves, extraordinary texts. Here, we should note their reliance on the unmarked presumption that doctors are overwhelmingly white, cis and male, a presumption unchallenged by scenes characterized by blatant racial and gender stereotyping or language that ranges from clunky to crude. My interest stems from their influence on the profession, where they are still regarded as

“de facto required reading by medical students preparing to enter their residency programs”.20 This influence permits an analysis that can realistically extend itself from the representation of profession within the novels to broader claims about how these representations have been internalized, since the books were published. When Jones compared Upton Sinclair’s 1925 novel,

Arrowsmith, to The House of God to demonstrate a general decline of the doctor hero between the

1920s to the 1970s, she justified their chronological disconnect by noting that “these two works clearly demarcate changes in the literary image of the physician during this century and point to underlying causes.”21 Their clarity of contrast offsets her analysis’s lack of historical detail.

“Images of physicians in literature”, she concludes, “can serve as an important barometer of changing cultural values, desires, and fears.”22 Jones’s reading of the novels as barometers is itself a barometer of their presence within the hidden curriculum of medical education. My aim here, however, is not simply to measure the changing cultural values, desires and fears represented by the novels as bookends to O’Mahony’s Golden Age. Shifting Jones’s analysis to include The

Citadel affords a comparison that exceeds either the sociology of either UK or US medical contexts or an overly straitened historicism. It demonstrates a trend towards a shame-to-cynicism conversion in fictions that represent the institutionalization of health professional development.

Goffman and the Institutionalization of Cynicism

Midway through The House of God, Berry, a clinical psychologist, invokes Erving Goffman to explain why her relationship with Roy, her boyfriend and the novel’s protagonist, has deteriorated dramatically in the four months since he began his medical internship. “Oh sure,” she remarks, “ there’s the camaraderie, and you’re right, the only reason men go to war is to die with their buddies, but it seems to me that what’s happening to you is the total institutionalization of the internship, á la Goffman”.23 We can take Berry’s statement as something of a signature statement for the novel.

Certainly, the physical institution of the hospital is foregrounded in the novel, which, after all, emphasizes itself a site, a house. There are further correspondences with social institutions of professional and personal masculinity. During the course of Roy’s internship, he uses rhetorically

and sexually heightened performances of masculinity to compensate for the general deterioration of his relationships with Berry, his teachers and his fellow interns. The phrase attends to the wider concern of the novel: the structural deformations wrought upon (male) junior doctors by their medical internships, which they make bearable through a homosocial “camaraderie” that surrogates for genuine care. In order to satirize this moral deterioration rather than condemn it,

Shem has Berry adopt a reflexive distance in her statement, established by the dry witticism about war and the informal academese mention of Goffman. Such moments of reflexive detachment are doubtless the reason why many readers repeat “cynical” in descriptions of the novel. The label is useful, insofar as it gestures to a feedback mechanism in the novel, linking cynicism to an institutionalized deterioration of care. Moments of cynicism in the novel are not merely responding to “the total institutionalization of the internship” or the problematic sexual politics of

“camaraderie” diagnosed by Berry; they also facilitate the expansion and perpetuation of these dynamics. As Roy disengages from his empathetic bonds for reasons of objectivity and self- protection, so the novel presents detachment, often taken to be a virtue amongst doctors, as analogous, even coterminous, with cynicism, especially as both develop in incomplete defense against shame.24

Berry’s invocation of Goffman invites Shem’s readers to think of the internship in terms of

Goffman’s total institutions, which, like Michel Foucault’s disciplinary institutions, employ clearly defined spatial limits to socialize its participants into certain patterns of group behavior.

For Goffman, “a total institution may be defined as a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life”.25 Certainly, Berry is right to

observe in Roy “the total institutionalization of the internship”; although he does not live at the hospital as Goffman suggests of other inmates of total institutions, Roy has undergone the necessary “mortification” of the self identified by Goffman, whereby links with the subject’s previous life are systematically stripped away. The novel is, after all, an account of Roy’s struggles as he internalizes the contradictory values of the House, arranged as a dialectic between the ostensible principle of medicine espoused by senior staff, to do everything for the patient always, and its more grounded antitheses “The Laws of the House of God” professed by their progenitor, the Fat Man. Indeed, The House of God might well be read as a Goffmanian allegory of hospital internships as total institutions. Read in this light, the already implicit connections between the titles of The House of God and The Citadel can be thought of as more than casual allusions to accommodation. They foreground the physical and social institutions of the medical establishment, against which the protagonists repeatedly hurl themselves. If anything, The Citadel emphasizes the social function of these total institutions over Goffman’s original concern with physical site, since there is no single physical space that incorporates all the heterogenous sites of institutional malfeasance observed by Andrew. Emphasizing physical and social space, however, remains insufficient because it does not explain the affective responses of Roy and his fellow interns, or of

Andrew and his colleagues. They do not simply become cynical because their eyes are opening to the “realities” of the medical establishment; rather, the medical establishment exerts an influence the doctors’ belief in their self-presentation, their role performance, in everyday life.

Goffman’s first work, The Presentation of Self in Everyday Life (1959), opens with a distinction between sincere and cynical role performance. The first chapter begins with the claim that an individual playing a part “implicitly requests his observers to take seriously the impression that is

fostered before them. They are asked to believe that the character they see actually possesses the attributes he appears to possess”.26 The performer may be sincere, “taken in by his own act”, or cynical, “when the individual has no belief in his own act and no ultimate concern with the beliefs of his audience”.27 But a cynical individual may also “delude his audience for what he considers to be their own good, or for the good of the community”: “practitioners who may otherwise be sincere are sometimes forced to delude their customers because their customers show such a heartfelt demand for it. Doctors are led into giving placebos [...] these are cynical performers whose audiences will not allow them to be sincere”.28 Building on Becker et al’s seminal anthropological work in medical education, later published as Boys in White (1961), Goffman notes that doctors may become cynical performers because their patients need them to be. This shifting of roles, from episode to episode, gestures towards a more gradual progression from

“conviction or insecure aspiration and ending in cynicism”.29 Goffman suggests professions such as medicine implicitly advocated this development, not only because it deludes the patient- audience, but “because they can use this cynicism as a means of insulating their inner selves from contact with the audience”.30

Following Boys in White, researchers have frequently returned to cynicism as an unfortunate consequence of medical training and practice, using it to describe a loss of idealism and concomitant deterioration of empathy.31 Such discussions typically open with already pathologized definitions of cynicism. Peng et al, for instance, take cynicism to be “a decline in empathy and emotional neutralization”.32 Such fine-grained definitions have evolved from earlier engagements with cynicism in the medical education literature, as a “disposition of people to find fault or doubt the sincerity of those expressing high-minded ideals and standards”.33 The

refinement of the term can be understood as a response to problems Loretta Kopelman outlined in the early attitude research conducted at medical schools, which, she found, did not seem

“sufficiently reliable or sensitive to perform the tasks some set for them. As measures, they seem problematic, unappreciative of their own value-laden assumptions, and of the diversity of moral lives, debates, and considerations”.34 Kopelman observes the problem of reliable attitude testing emerges from existing definitions of cynicism. More concrete definitions of cynicism, such as

Peng et al’s, do permit more rigorous attitude testing. However, more stringent definitions fail to address Kopelman’s main aim, which was to ascertain, as a matter of ordinary language use, what medical students themselves understand by the word “cynicism”.

Responding to Eron’s definition of cynicism, as “a contemptuous disbelief in man's sincerity of motives or rectitude of conduct, characterized by the conviction that human conduct is suggested or directed by self-interest or self-indulgence”, Kopelman notes a contradiction: “if human conduct is directed by self-interest or self-indulgence, if that is what we are like, then why is holding the view that this is true a contemptuous disbelief in man's sincerity of motives?”35 Value-laden assumptions about cynicism obscure, to Eron at least, the contradictions latent in his own definition. If we resolve this contradiction, by observing a scale variance between the self- indulgence of the human animal writ large and an individual’s disbelief in the sincerity of motives, we can begin to see that individualized definitions of cynicism are necessary but insufficient to

Kopelman’s actual aim in her essay: to understand why students use the word cynicism when describing their disappointment about their education. While the move towards tighter definitions improves our understanding of empathy attrition, it does so at the expense of a more complex discussion of cynicism’s relations to individuals, groups, and cultures. That is to say, in attempting

to fasten cynicism down to a readily observable set of precepts, recent attitude research loses the valency cynicism offers, over other near-synonyms like skepticism or “empathy decline”.

A different approach would address the ways in which cynicism comes to be associated with particular roles performed within medical contexts, as a product of certain discourses.36 Here, the influence of The Citadel and The House of God is not inconsequential, since both novels offer two comparable typologies of medical cynicism. Indeed, the characters that personify different cynical approaches to the medical system simply introduce the protagonists to the different routes to professional development. These flat, one-dimensional characters should not be read as

“individualized personalities”, following Peter Sloterdijk, “but rather types, that is, social characters and characters of a period […] literary figures who can be used to demonstrate archetypal features of cynical consciousness”.37 These types differ according to the affective tone of the novels, which are strikingly different: whereas the tone of The Citadel is sentimental, characterized by scenes of emotional excess, the tone in The House of God remains satiric, even at its most poignant, which might account for why “its urgent messages are eclipsed by its riotous, cynical, and deliciously quotable moments, especially the 13 brilliant aphorisms known as The Fat

Man’s House Laws”.38 In The Citadel, Andrew finds “a strange stimulus” in Philip Denny,

Andrew’s model for the good cynic and his sometime moral mentor, and his “pessimism, in his skepticism, his cold and measured cynicism”.39 When they first meet, Philip is “blandly complimentary” of Andrew’s dispensing of what Philip calls “the dear old mumbo-jummery”

(Citadel 12). Then “with his assumed air of confidence, more blandly offensive than ever”, he laughs with “a mocking appreciation” that Andrew takes as “an insult” (Citadel 13). But, in a sentimental turn, Philip “dropped his mocking irony, his ugly features turned morose again. His

tone, though bitter, was serious” (Citadel 13). Cronin’s explicit marking of the shift between the jocular and the serious, his heavy-handed use of adjectives, differentiates the sentimentalism of

The Citadel and Philip’s counterpart in The House of God, the Fat Man: “the Fat Man, with his

LAWS OF THE HOUSE and his approach to medicine that at first I thought was sick but that gradually I learned to be the way it was” (House 12). “Cynic”, Roy accuses him, to which the Fat

Man replies, “eyes twinkling”, ‘Ah, yes,’” (House 52).

The difference between Philip and the Fat Man affects the way these two exemplars of “good cynicism” address the problem of excess medical intervention. Both are presented as supremely gifted clinicians who advocate minimal medical intervention: Philip, in the interests of promoting scientific medicine free from quackery, and the Fat Man, because, in the words of the 13th Law of the House, “the delivery of medical care is to do as much nothing as possible” (House 391). For both Cronin and Shem, cynicism is acceptable only when combined with clinical excellence.

Elsewhere, Robbie Duschinsky, Jane Macnaughton and Arthur Rose have argued for a more complex understanding of cynicism than is here presented, precisely because it needs to be understood as a critical coping mechanism, untrammeled by imperatives of excellence.40 By contrast, even the apparent openness to cynicism in these novels can be seen to be circumscribed by a value system oriented towards excellence and generic constraints oriented towards clinical sincerity. After all, Cronin has Philip break his cynical mask whenever he ventriloquizes Cronin’s own belief in the importance of the scientific method. If Shem’s Fat Man never disturbs the delicate balance between sincere care and ironic self-positioning, this is more a marker of generic differences between the novels than an openness to a reconsideration of the role of cynicism as

such: the sentimental The Citadel demands an excess of emotion, where the satiric The House of

God demands its dissimulation.

Bracketing this generic difference helps us find shared patterns of relation. Both sentimentalism and the satire rely more on types than on fully developed characters, since types act as exponents of particular values, attitudes or behaviours. Accordingly, the novels correlate particular characters to forms of cynicism. This correlation suggests a common typology in both novels: the “good cynicisms” of Philip and the Fat Man are contrasted the self-interested cynicisms of careerists like

Maurice Gadsby and the Slurpers, and the profit-motivated cynicisms of Freddie Hamson and

Howie Greenspoon. While these cynicisms land differently, according to the generic tone of each book, they nevertheless bear enough features in common, to warrant their consideration as a typology. Maurice Gadsby, the careerist doctor who takes credit for Andrew’s work on silicosis in

The Citadel, plays the system for his own benefit: according to Andrew’s friend, Hope, he’s a

“little thruster […] but he’s not interested in research. He’s only interested in himself” (Citadel

228). As befits Shem’s less earnest satire, all such “thrusters” are referred to as Slurpers in The

House of God, defined in the glossary as “House Academics, striving to lick their way up the academic medical cone toward the one position at the top—the Chief” (House 396). This social capital may be an aspiration for Andrew’s friend, Freddie Hamson, and Roy’s fellow intern, Howie

Greenspoon, but they are equally interested in material gain. When Freddie sees Andrew at a conference, he debunks the suggestion he is there to keep “up to date”: “no, no, old man it’s the contacts you make that matter […] I’ve got my eye on a nice little room up West where a smart little brass plate with Freddie Hamson, MB, on it would look dashed well” (Citadel 70). “You know how it happens”, Freddie summarizes the state of the system for Andrew, “Reciprocity. You

scratch my back and I’ll scratch yours” (Citadel 70). Howie’s material interest is more comically depicted: he wants to win a prize for bringing in the most postmortems.

Andrew and Roy embrace a transitional cynicism, as they experience a gradual attrition of their earlier naïve idealism: Andrew decides to pursue a profitable private practice against the wishes of his wife, Christine, while Roy becomes less and less willing or able to respond to his patients, then his friends, and finally his girlfriend Berry. Christine describes Andrew as “falling victim to the very system you used to run down, the thing you used to hate”, eventually exhorting him:

“Don’t, don’t sell yourself!” (Citadel 316; 317). Berry repeatedly describes the internship as “a disease” (House 336), while trying to remind Roy of his core moral values. When both Andrew and Roy begin affairs with other female characters, it marks the deleterious effects of their cynicism and it is only when they become reconciled with their partners that they begin to transition away its more toxic effects.

The women are, themselves, denied more complex inner lives, functioning principally as moral compasses to their male partners. Given this position, the protagonists’ transition, then, from idealism to cynicism to tempered realism should not be distinguished from the sexism that facilitates its representation. Women in both novels are either sexualized objects or paragons of moral virtue, and generally denied any agency beyond their service to the male protagonists, a condition in keeping with the general sense that the novels rely on types rather than characters.

This is not just because, as Brenda Beagan would note of the everyday inequalities experienced in medical school, the “latent culture” is one that has historically preferred white, middle-class, heteronormative men, it also speaks to the underappreciated sense that, in order to be recognized

as a cynic (whether speaking truth to power, or accruing social or economic capital), one must already be included within the culture, as a voice whose protests warrant serious attention.41 The partners of the protagonists are, then, foils to the voices that actually count, those of Philip and the

Fat Man; their prescient warnings given as much credence as Cassandra’s, and for much the same reason.

White male characters are easily identifiable as cynics, whereas female characters are denied the positions necessary to exert this disposition, as, indeed, are racialized characters, like Chuck in

The House, or classed characters, like Conn in The Citadel, who tend to be cast as victims of circumstance. If the typology invites reflection on cynicisms at work in different medical systems, the sexism that undergirds it suggests we read this typology as more than simply a matter of personal disposition. It must be read with an eye to power and privilege. The typology reframes the characters as products of the system, where their attitudes may be taken as symptoms of its flaws. If it is immediately apparent in the sexism, the racism, the classism at work in both novels, it is also entirely consistent with their internal concern with a blinkered reform that fails to address these very issues. This unwritten blank normativity sets up the ostensible reform offered by the novels as a false offering, inviting the same generally pervasive cynicism about medical systems that they seek to diagnose.

Such reflexive problems with cynicism are reproduced in the novels’ most critical moments. In

Andrew’s impassioned plea at his General Medical Council referral hearing, he accuses “the whole profession” of being “too intolerant and smug. Structurally, we’re static. We never think of advancing, altering our system”, a further condemnation added to his earlier summary: “If we go

on trying to make out that everything’s wrong outside the profession and everything is right within, it means the death of scientific progress” (Citadel 417; 416). Roy’s comparable moment of realization is his summation of “the one truly great American Medical Invention: the creation of a foolproof system that took sincere energetic guys and with little effort turned them into dull, grandiose docs who could live with the horror of disease and the deceit of ‘cure,’ who could ‘go with’ the public’s fantasy of the right to perfect health devoid of even the deterioration of age”

(House 378). Andrew’s response is given in public and reconciles his desire to continue with medicine by invoking a new value system based on scientific (i.e. evidence-based) medicine. By contrast, Roy’s realization is largely self-directed, and, rather than attempt to change the system, as Andrew does, he chooses to resign from his fellowship and move into psychiatry. In a moment that parallels Andrew’s decision to speak truth to power at his review, Roy considers telling the

Leggo, Chief of Medicine at the House, the problems with the program: “Should I tell him? No.

Too cruel […] I’d ask him, give him a way to talk about it, a way of the judgement he was begging from me” (House 384). When, however, the Leggo decides “things are fine”, Roy feels “relieved.

Somehow he’d pulled things back up around him, and could go on, impenetrable, cold” (House

384). Insofar as cynicism is a coping mechanism, it provides a structural means for both the administration and the staff to “go on”, “relieved” by an interminable opposition that encodes resistance into the conditions of the system’s survival. This ostensible difference, between

Andrew’s activism and Roy’s quietism, disguises their mutual privilege: they enjoy the recognition that their voices count, if only by their readers.

The novels, then, for all that they appear to be written “outside the system”, should be understood as elements within the medical apparatus, legitimizing coping strategies that mask cooption as

resistance. Shem has himself written of The House of God as a resistance narrative, where resistance, following Anton Chekhov’s thoughts on literature, can be understood as “life as it should be in addition to life as it is”.42 In a 2002 article for Annals of Medicine, entitled “Fiction as Resistance”, Shem quotes Chekhov to explain his acts of resistance during his internship (the inspiration for The House of God). Presented with “a series of moments—which I now call ‘Hey wait a second!’ moments—those moments many of us experience every day when we see, hear, or feel that something is unjust, cruel, militaristic, or simply not right”, Shem and his colleagues

“resisted”, by taking “‘life as it is’ and turn[ing] it on the spindle of compassionate action to make it more like ‘life as it should be’”.43 Shem’s account of this resistance “to brutality and inhumanity, to isolation and disconnection” presents a commendable response to the challenges of the internship, but it fails to address the novel’s concern with cynicism.44 By recasting the narrative as a matter of resistance, Shem elides the very difficulties the narrative claims to work through: the tendency of the interns to shed their values in order to survive and the fact that it describes “all in all a pretty typical year”: “all across the country […] terns were being allowed to be angry, to accuse and cathart and have no effect at all” (House 371).

Roy realizes that his coping is not resistance during a performance by the mime, Marcel Marceau.

“What the hell had happened to me?” he asks. “Something had died”; “my calm had been the calm of death” (House 334; 335). If cynical detachment has killed this “something”, his naïve idealism, his enthusiasm, he only becomes aware of it because the performance awakens in him a shame response. As he watches he finds himself “flooded by feeling” (House 334). Turning to the prosthetic metaphor, he imagines this as a “hearing aid for all my senses”. That this occurs during a performance by Marcel Marceau, however, is not incidental to my emphasis on cynicism and

shame, against, say, the language of detachment and despair, or what Roy calls “calm” and “an acrid chasm”. For it is Marceau’s performance that triggers in Roy the realization of the cynicism of his own performance and brings about the “desperate clawing” of shame.

The last mime skewered me: The Maskmaster switched back and forth a smiling mask, a

crying mask, faster and faster, until finally the smiling mask got stuck on his face and he

couldn’t remove it. The human struggle, the frantic effort to be rid of a suffocating mask;

trapped, writhing, wearing a smile. (House 334)

Switching between the masks, “faster and faster”, destabilizes any sense of an emotional attachment to either smiling or crying. This makes the “struggle” to remove the smiling mask, after it becomes stuck, the more poignant, since it is a false presentation of the self. The pathological extreme of Goffman’s cynical clinician, Roy responds to the Maskmaster’s depiction of a person trapped in a cynical performance, because he too must perform for an audience who “will not allow him to be sincere”. This shifting of roles, from episode to episode, gestures towards a more gradual progression described in the novel, from “conviction or insecure aspiration and ending in cynicism”.45 If the story of the internship is the development of cynicism, the plot of The House of

God is the realization of its pathologies, through shame.

If we return to Berry’s sardonic remark about camaraderie and war, quoted at the beginning of this section, we find an implicit link between the medical shaming practices presented in the novel and those endured in military training, which, as Bonnie Mann explains, are often meant to forge new forms of community between soldiers. Mann identifies, in acts of ritual humiliation, a shame-to-

power conversion. Shame-to-power conversions describe shaming practices that produce (“are converted into”) displays of compensatory hypermasculinity. Such practice, demonstrates Mann, are encouraged in institutional contexts, whether medicine or the military. Thus alerted, we can begin to find in Goffman’s “total institution” of the internship similar forms of “shame-to-power conversion”. Not only does this identification help to explain why sexist, misogynistic and racist tropes, often dismissed as merely regrettable, are integral to the novel’s construction, it also connects shame to the processes by which the interns develop a moral distance from their work and their patients, mirrored, in turn, by the novel’s use of satiric reflexivity as a formal conceit.

Adapting Mann’s notion of a shame-to-power conversion, we might identify this moral distance as the product of a shame-to-cynicism conversion.

Bonnie Mann and the Shame-to-Cynicism Conversion

The Citadel and The House of God are marked by sexism, casual misogyny, racism and classism.

However, we should not read these features as “regrettable” features of novels that are “products of their time”.46 They are absolutely integral to the novels’ development of what Mann, writing of sovereign masculinity, calls shame-to-power conversion. Sovereign masculinity, her term for the relation between masculine individuals and “sovereignty as it is imagined and practiced by the nation”, “is characterized by a denial of both physical and intersubjective vulnerability”.47 Since vulnerability is “ubiquitous in human existence”, there is a need to convert this vulnerability into something else: sovereign masculinity. Shame-to-power conversion describes this production, or conversion process. Sovereign masculinity relies, at its core, on shame-to-power conversion, whereby the man is offered some form of power, as an antidote to shame, an honor that “equates

with loyalty, first and foremost to the brotherhood he has been invited to enter”.48 Such sites, for

Mann, may be found in the hyperbolic displays of agency that characterize militarized hypermasculinity. Such militarized hypermasculinity is, it seems to me, to be at work in Berry’s comment, “there’s the camaraderie, and you’re right, the only reason men go to war is to die with their buddies”. So, while Mann’s work may not, initially, appear relevant to the more staid male figures in The Citadel and The House of God, her reading of masculinity as the expression of national sovereignty may be translated to these treatments of clinicians for two overlapping reasons: the oblique interest in national sovereignty in both novels and their expression of their protagonists’ painfully toxic masculinity.

Both novels do engage substantially, if obliquely, with the political environment of their particular moment, suggesting that the sickness they diagnose in the medical system reflects a more pervasive sickness of the state itself. The House of God makes this explicit: it tracks the passage of time in the internship, and the gradual deterioration of Roy’s ideals, through references to then US

President Richard Nixon’s responses to Watergate from July 1973 to the end of the internship a month before Nixon’s resignation. The sickness, then, that Berry describes in the interns fits into a wider malaise that affects the US nation. The Citadel is less explicit about the political dimensions of the medical system, but Cronin does suggest that State control would be as bad, if not worse, than the corruption of private practice: “‘It’s the system’, [Andrew] thought savagely,

‘it’s senile. There ought to be some better scheme, a chance for everybody – say, oh, say State control!’ Then he groaned, remembering Doctor Bigsby and the MFB. ‘No, damn it, that’s hopeless – bureaucracy chokes individual effort – it would suffocate me’” (Citadel 248). Such expressions against the failure of the system also depend on the aforementioned sexism, that denies

either Christine or Berry the full development of their characters, and their relatively passive acceptance of their partners’ infidelity. Far from being simply supplemental, “blue” writing, the graphic descriptions of sexual exploitation in The House of God can be understood, then, to be absolutely pivotal to the construction of masculinity in the novel, as an assertion of strength over vulnerability that offsets the impasse the (male) interns face, between an unrealizable ideal

(“idealized care”) and an unworkable system (“total institution). This impasse produces a shame that the system cannot but disavow, if it is to continue to function. This disavowal converts the shame into a violence that either projects outwards, through detachment or sexual exploitation, or inwards, as self-harm as for the intern who commits suicide, Potts. Shame is a constitutive feature of both narratives that remains conspicuous by its relative absence.

Shame, as Luna Dolezal and Barry Lyons observe, is

a negative emotion that arises when one is seen and judged by others (whether they are

present, possible or imagined) to be flawed in some crucial way, or when some part of one's

self is perceived to be inadequate, inappropriate or immoral. It is what is called a self-

conscious emotion in that the object of shame is oneself and, furthermore, it involves an

awareness of how other people view the self.49

Lyons, Dolezal and Matthew Gibson have elsewhere shown how shame can have a debilitating effect on clinicians: “they may conceal the problem; they may be aggressive and deflect blame elsewhere; they may feel unworthy of being a doctor and ‘drown in shame’”.50 As Roy watches

Marcel Marceau, he describes a parallel experience of shame: “along with this burst of feeling

came a plunging, a desperate clawing plunge down an acrid chasm towards despair” (House 334).

Narratively, Roy’s experience of shame in the theatre is the point of realization upon which the bildungsroman turns. Importantly, it does not take place in a clinical encounter. Located in a theatre, Marceau’s performance highlights for Roy the cynicism demanded of him in his own performative self-presentation in his clinical encounters. If the conversion of shame into cynicism allowed Roy to survive his internship up until that moment, the realization of the full impact of this cynicism threatens to collapse him back into “an acrid abyss”.

Roy’s encounter highlights the shame involved in the cynical performance of a clinician’s self- presentation. Andrew’s equivalent moment in The Citadel is, arguably, a more conventional encounter with shame for the physician: a sentinel moment where his complicity in a botched medical procedure leads to a patient’s death. Charles Ivory, the surgeon who commits the error, is described as fully self-presenting as competent: “no one more completely resembled the popular conception of the great surgeon […] He had the fine supple hands with which popular fiction always endows the hero of the operating theatre” (Citadel 313). However, while he “never looked more exactly like the great surgeon of fiction”, Charles is incompetent, choosing to puncture a haemorrhagic cyst, rather than ligature its pedicle. As he sees this, “a wave of horror swept over

Andrew” (Citadel 355). He realizes Charles “can’t operate, he can’t operate at all”. As the patient,

Harry Vidler, bleeds out, Charles continues the procedure benignly, finishing only after the patient has died. While Charles is unaffected, Andrew feels “sick, shattered, on the verge of a complete collapse” (Citadel 357). Andrew’s psychological trauma is accompanied by a shame that manifests in anger at himself and at Charles: “He was trembling, infuriated by the consciousness of his own weakness in this awful situation which Ivory had sustained with such cold-blooded nerve” (Citadel

357). Like Roy in The House of God, he forecloses his experience of shame with the numbness of a battle-field trauma:

The dreadful shock of the calamity had caught him with the destructive violence of an

explosive shell. It was as though he, also, were eviscerate and empty. Yet still he moved

automatically, advancing as might a horribly wounded soldier, compelled by machine-like

habit to perform the duties expected of him (Citadel 358).

Cronin’s recourse to military style metaphor can, of course, be understood biographically, through his service during the First World War, or historically, as an understated reference to the origin of the Western doctor in medieval militarism. Certainly, it reinforces the sense that the novel is flirting with the same sovereign masculinities theorized by Mann. What it signals for my argument, however, is the foreclosing of an experience of shame as a maiming of the self. For our purposes, we can side-step arguments about whether Andrew’s feelings are best described as guilt or shame, since whatever the object cause, these feelings rebound directly upon Andrew himself. Philipp

Wüschner suggests that, rather than opposing shame and guilt, we might read them “as a complex of distinguishable emotions that nevertheless share […] a transgression as [their] formal object, but they differ in its evaluation as well as in their orientation (towards the self in the case of shame towards the other in the case of guilt)”.51 This shameful event is the consequence, Andrew decides, of his profit-driven practices, and he begins, as a result, to recuperate his previous idealism. It is, then, the hinge moment upon which the plot of The Citadel turns.

But if his subsequent actions alleviate whatever guilt he feels, he never resolves his shame over the encounter. This is demonstrated, near the end of the novel, when he approaches Mrs Vidler,

Harry’s widow, “as though the mere sight of her might help him, give him, in some strange manner, appeasement from his suffering” (Citadel 404). This “strange manner” might be interpreted as

Andrew’s attempt to turn his shame into a more resolvable economy of guilt, “that all the calamity of these last months came in punishment for Harry Vidler’s death” (Citadel 404). When Mrs Vidler refuses to blame him, however, claiming “Harry couldn’t have had a better nor a kinder nor a cleverer doctor than yourself”, he sees that “she would never believe him. She had her illusion of

Harry’s peaceful, inevitable, costly passing. It would be cruelty to shake her from this pillar to which she clung so happily” (Citadel 405). While we may not think highly of Andrew’s self- presentation in this encounter, he experiences Mrs Vidler’s refusal to allow him to be sincere as intrinsically shaming: “the encounter, far from reassuring or consoling him, served only to intensify his wretchedness. His mood underwent a complete revulsion” (Citadel 405). The requirement that he be cynical, in his self-presentation, reinforces Andrew’s feelings of shame. If, according to Mann, feelings of shame produce, are converted into, a disavowal of vulnerability that becomes associated with power, this process, when mapped in The Citadel and The House of

God, produces comparable forms of detachment that come to be associated with cynicism.

Although we might call this a shame-to-cynicism conversion, it is clear that this process does not simply move in one direction: rather, it creates a feedback loop, whereby cynicism incites further feelings of shame, demanding further detachment, cementing further cynicism.

Conclusion

Even as Andrew realizes that he abhors his cynicism, he feels most acutely his shame. Andrew’s personal circumstances reflect a broader systemic concern, linking cynicism and shame. But we can only understand this dynamic, the shame-to-cynicism conversion, as it operates within a larger medical system. Lyons, Dolezal and Gibson argue, the effects of shame are compounded by the medical system, or apparatus, which self-selects for “high-achieving perfectionists for whom failure is both uncommon and unwelcome”.52 Shame, then, may be deeply distressing on a personal level, but it also functions as a (flawed) regulating device for medical institutions. Writing more explicitly of shame’s affective economy in relation to the Foucauldian dispositive, Wüschner argues that these systems of relation demand, as their necessary complement, the production of affects (like shame), through affective arrangements. Affective arrangements produce “certain affective dynamics […] by conjoining multiple actors, facilitating affective resonance between them and giving (or taking away) opportunities to act on emotions”.53

Affective arrangements, however, are not elements of dispositives like any other. They not

only belong to the “system of relations” of these elements, but amplify and intensify these

very relations. The affective resonance they produce can help to constitute the dispositive,

but may also transform and change it – abruptly or over a longer course of time.54

Affective arrangements describe repeated patterns of affective behavior, which, when considered individually, seem to be isolated (and isolating) cases, but, when taken as a group, demonstrate clear trends. Shame amplifies and intensifies cynical relations in the novels, which, in turn, shape the percepts of shameful behavior within the medical apparatus. The novels, then, bring to light a dynamic that operates between clinician shame and clinician cynicism, wherein both might be said

to be co-produced. Cynicism can be understood as a reaction to feelings of shame, warding off some of its worst consequences. Shame, in turn, might arise when observing cynical behavior, especially when that observation implicates the subject. Whereas both novels describe this dynamic as a personal journey, experienced by each protagonist alone, their close mirroring of the dynamic suggests that it may be understood as part of wider systems, Goffman’s total institution.

We can find this blurring of cynicism and shame, if we return, once more, to Berry’s invocation of Goffman. It occurs at the beginning of a fight, whose narrative function is to expose Roy’s changing self-image as a doctor and his feelings of guilt for embarking on a clandestine affair with

Molly, a nurse at the hospital:

We were fighting about Dr. Sanders’ long dying and about the illusion in my father’s letters

and about my plethora of absent role models and the blossoming idea that the gomers were

not our patients but our adversaries, and most of all we were fighting over the guilt that I

felt for having Molly in a dark corner of the ward standing up (House 150)

Within Roy’s dissection of their fight, one can find traces of Goffman’s The Presentation of the

Self in Everyday Life, but also his work on Stigma. For the fight, if we continue to read it “with the grain” of Shem’s first person narration, turns on Roy’s belief in his performance of the doctor role

(what Goffman describes as the “belief in the part one is playing”) and his “guilt” for his infidelity

(Roy’s reference to the “dark corner of the ward” suggests that his anxiety stems from concerns about “deviance”, rather than about the act itself).55 Given that Roy commences the affair because

“one way to survive was sexually” (House 115), his “guilt” suggests a structural relation in the

novel between sex and professional survival (and, by extension, presentations of the self). By introducing Goffman, Berry does not simply open up the novel to reflections on total institutions, she also invites us to read it along two axes: the degree to which Roy is “taken in by his own act” on an axis of sincerity-cynicism, and the extent to which he begins to perceive “his own attributes as being defiling to possess, and [that] he can readily see himself as not possessing”, or an axis of guilt and shame.56 What I have sought to demonstrate in this essay is the relation between these two axes, whereby shame is converted into cynicism, and cynicism into shame.

Comparing The Citadel with The House of God, in light of their subsequent reception, indicates a generalized recognition of cynicism’s importance in developing resources for negotiating medical systems. In The Citadel, cynicism frames frustrations with archaisms in the medical system, coupled with the desire to reform and modernize. By contrast, The House of God’s frustration with the medical system is expressed precisely against those modernizing reforms and the resulting

“brutal and dehumanizing experience” for interns. If both novels draw on cynicism’s resources to express frustration with sclerotic systems, whether archaic or dehumanizing, their changing approach to cynicism betrays a further change to physician shame. Whereas physician shame remains tightly controlled in The Citadel, to differentiate self-aware excellence from ignorant incompetence, it is largely unbounded in The House of God, an affective condition to be reveled in. Despite these ostensible differences, the two novels share a formal concern with the relation between shame and cynicism, here described as a shame-to-cynicism conversion. The abiding influence both novels have on the self-image of clinicians in formation suggests avenues for further work, to establish whether such a conversion operates in reality as it does in fiction.

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1 See, for example, Arthur Rose, Robbie Duschinsky, and Jane Macnaughton, “Cynicism as a Strategic Virtue”, The Lancet 389, Issue 10070 (2017). 2 For a notable exception to the relative dearth of literature on shame in medical education, see Will Bynam’s work, for example William Bynam IV, Anthony R. Artino, Jr; Sebastian Uijtdehaage; Allison Webb; Lara Varpio, “Sentinel Emotional Events: The Nature, Triggers, and Effects of Shame Experiences in Medical Residents”, Academic Medicine 94, 1 (2019). 3 See, for instance, Ross Mckibben, “Politics and the medical hero: A. J. Cronin’s The Citadel”, English Historical Review 123 (2008); Alan Davies, A. J. Cronin: The Man who created Dr Finlay. (London: Alma Books, 2011); Sally Dux, “The Citadel (1938): Doctors, Censors and the Cinema”, Historical Journal of Film, Radio and Television 32, No. 1 (2012); S. O’Mahony, “AJ Cronin and The Citadel: did a work of fiction contribute to the foundation of the NHS?”, Journal of the Royal College of Physicians Edinburgh 42 (2012); Christopher Meredith, “Cronin and the Chronotope: Place, Time and Pessimistic Individualism in The Citadel”, North American Journal of Welsh Studies 8 (2013). 4 Adam Kay, “Introduction”. In The Citadel, 2-5. (London: Picador, 2019), 2. 5 Davies, Cronin, 145. 6 Meredith, “Chronotope”, 51. 7 Dux, “Cinema”, 10. 8 O’Mahoney, “Fiction”, 175. 9 See John Updike, “Mayhem at the Hospital”. In Return to The House of God (Kent OH: Kent State UP, 2008); Martin Kohn; Carol Donley, Return to The House of God: Medical Resident Education 1978-2008 (Kent OH: Kent State UP, 2008); Jeremy Samuel Faust, “The House of God at Age 40-An Appreciation”, JAMA 322, no. 6 (2019). 10 Kenneth M Ludmerer, “Residency Education since The House of God”. In Return to The House of God (Kent OH: Kent State UP, 2008), 22. 11 Ibid. 12 Ibid. 13 Anne Hudson Jones, “Images of physicians in literature: medical Bildungsromans”, The Lancet 348, Issue 9029, 14 September 1996, 734. 14 O’Mahony, “Fiction”, 174. 15 Denis Noble, “The Birth of The House of God”. In Return to The House of God (Kent OH: Kent State UP, 2008), 5. 16 Seamus O’Mahony, Can Medicine Be Cured?: The Corruption of a Profession (London: Apollo, 2019). O’Mahony’s Can Medicine Be Cured? demonstrates the continued presence of the insider-outsider critique in medical non-fiction that characterizes the extra-novelistic intentions of The Citadel and The House of God. 17 Oscar Wilde, “Lady Windermere’s Fan”. In The Importance of Being Earnest and Other Plays (Oxford: Oxford UP, 2008), 45. 18 Osler, William. “Aequanimitas”. In Aequanimitas; with other addresses to Medical Students, Nurses and Practitioners of Medicine (Philadelphia: P. Blakiston’s Son & Co, 1925), 8. 19 Ibid, 5. 20 Glenna C Chang, The Hidden Curriculum: Hazing and Professional Identity (Seattle: Seattle Pacific University PHD Thesis, 2011), 6. 21 Jones, “Bildungsroman”, 734. 22 Ibid, 736. 23 Shem, House, 149. Hereafter in parentheses. 24 For a detailed discussion of detachment as a medical virtue, see Agnes Arnold-Forster, “‘A small cemetery’: death and dying in the contemporary British operating theatre”, Medical Humanities, Published Online First: 25 July 2019. 25 Erving Goffman, Asylums (New York: Anchor Books, 1961), xiii. 26 Erving Goffman, The Presentation of the Self in Everyday Life (London: Penguin, 1990), 28. 27 Ibid. 28 Ibid, 29.

29 Ibid, 31. 30 Ibid. 31 Howard Becker; Blanche Geer; Everett C. Hughes; Anselm L. Strauss. Boys in White: Student Culture in Medical School (Chicago: University of Chicago Press, 1961), 419-433. 32 Jenny Peng; Chantalle Clarkin; Asif Doja, “Uncovering cynicism in medical training: a qualitative analysis of medical online discussion forums”. BMJ Open 8 (2018), 1. 33 Loretta Kopelman, “Cynicism among medical students”, JAMA 250, No. 15 (1983), 2006. 34 Ibid, 2009. 35 Ibid. 36 For an expanded account of sincere and cynical (or deep and shallow) role performances, see Susie Scott, Negotiating Identity: Symbolic Interactionist Approaches to Social Identity (London: Polity Press, 2015), especially Chapter 4. 37 Peter Sloterdijk, Critique of Cynical Reason. Trans. Michael Eldred (Minneapolis: University of Minnesota Press, 1987), 155. 38 Faust, “House”, 488. 39 A. J. Cronin, The Citadel. Intro. Adam Kay (London: Picador, 2019), 21. Hereafter in parentheses. 40 Rose, Duschinsky, Macnaughton, “Cynicism as a strategic virtue”. 41 Brenda Beagan, “Micro Inequities and Everyday Inequalities: “Race,” Gender, Sexuality and Class in Medical School”, The Canadian Journal of Sociology / Cahiers Canadiens De Sociologie 26, no. 4 (2001), 585. 42 Samuel Shem, “Fiction as Resistance”. The Annals of Internal Medicine 137, no. 11 (2002), 934. 43 Ibid. 44 Ibid, 935. 45 Goffman, Presentation, 31. 46 Kay, “Introduction”, 2. 47 Bonnie Mann, Sovereign Masculinity: Gender Lessons from the War on Terror (Oxford: Oxford UP, 2014), 4; 109. 48 Ibid, 121. 49 Dolezal Luna; Barry Lyons. “Health-related shame: an affective determinant of health?” Medical Humanities 43 (2017), 257. 50 Barry Lyons; Matthew Gibson; Luna Dolezal, “Stories of Shame”, The Lancet 391, no. 10130 (2018), 1569. 51 Philipp Wüschner, “Shame, Guilt, and Punishment”. Foucault Studies 23 (2017), 96. 52 Lyons et al, “Stories”, 1568. 53 Wüschner, “Shame”, 92. 54 Ibid. 55 Goffman, Presentation, 28; Erving Goffman, Stigma (London: Penguin, 1990), 167. 56 Goffman, Presentation, 28; Goffman, Stigma, 18.